EHB Benchmark Chart Template 06 01 12 by 5FfL0v

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									                                                                                  ESSENTIAL HEALTH BENEFITS COMPARISON MATRIX
                                                                                       FOR MEDICAID BENCHMARK DECISION
                                                                                                                                                                                                   _
Benefits provided by potential benchmark major medical plans
Grouped in the 10 categories of Essential Health Benefits required by the ACA


                                                                                                                                                     Federal Employee
                                                                                Medicaid                         HMO      State Employee Plans                                    State Mandates
                                                                                                                                                     Health Benefit Plan
                                                                                                                                                   Blue Cross Blue Shield
Benefits
                                                                                                                                                      Standard Option
1. Ambulatory Patient Services
Primary Care Visit to Treat an Injury or Illness                                                                                                              Yes
Specialist Visit                                                                                                                                              Yes
Other Practitioner Office Visit                                                                                                                               Yes
(Nurse, Physician Assistant)
Outpatient Surgery:                                                                                                                                           Yes
Physician/Surgical Services
Outpatient Facility Fee                                                                                                                                       Yes
(e.g., Ambulatory Surgery Center)
Home Health Care Services                                                                                                                                       Yes
                                                                                                                                                   (maximum 25 2-hour visits
                                                                                                                                                             per year)
Skilled Nursing Facility                                                                                                                                        Yes
                                                                                                                                                    (limited to members with
                                                                                                                                                   Medicare Part A coverage)
Hospice Care                                                                                                                                                    Yes
Podiatry                                                                                                                                                        Yes
                                                                                                                                                 (related to medical condition)

Breast Cancer Outpatient Treatment Services                                                                                                                  NSP
Transportation for Medically-Necessary Services                                                                                                               No
                                                                                                                                                 (except when associated with
                                                                                                                                                      inpatient hospital)
Family Planning Services                                                                                                                                     Yes




Supported by a grant from the Robert Wood Johnson Foundation’s State Health Reform Assistance Network program.                                                                               Page 1_
                                                                                  ESSENTIAL HEALTH BENEFITS COMPARISON MATRIX
                                                                                       FOR MEDICAID BENCHMARK DECISION
                                                                                                                                                                                                   _
                                                                                                                                                     Federal Employee
                                                                               Medicaid                          HMO      State Employee Plans                                    State Mandates
                                                                                                                                                     Health Benefit Plan
                                                                                                                                                   Blue Cross Blue Shield
Benefits
                                                                                                                                                      Standard Option
1. Ambulatory Patient
2. Emergency Services Services
Emergency Room Services                                                                                                                                       Yes
Emergency Transportation/Ambulance                                                                                                                            Yes
Urgent Care Centers or Facilities                                                                                                                             Yes
3. Hospitalization
Inpatient Medical and Surgical Care                                                                                                                           Yes
Inpatient Physician and Surgical Services                                                                                                                     Yes
Transplants                                                                                                                                                   Yes
                                                                                                                                                     (for specified organs)
Antineoplastic Therapy Drugs (Chemotherapy)                                                                                                                   Yes
4. Maternity and Newborn Care
Prenatal and Post-natal Care                                                                                                                                  Yes
Delivery and All Inpatient Services for Maternity Care                                                                                                        Yes
Newborn Child Coverage                                                                                                                                        Yes
5. Mental Health and Substance Use Disorder Services (including behavioral health treatment)
Mental/Behavioral Health Inpatient Services                                                                                                                   Yes
                                                                                                                                                  (precertification required)
Mental/Behavioral Health Outpatient Services                                                                                                                  Yes
Substance Abuse Disorder                                                                                                                                      Yes
Inpatient Services
Substance Abuse Disorder                                                                                                                                      Yes
Outpatient Services
Autism Therapy (ABA)                                                                                                                                           Yes
                                                                                                                                                 (criteria must be met; limited
                                                                                                                                                     to certain procedures)




Supported by a grant from the Robert Wood Johnson Foundation’s State Health Reform Assistance Network program.                                                                               Page 2_
                                                                                  ESSENTIAL HEALTH BENEFITS COMPARISON MATRIX
                                                                                       FOR MEDICAID BENCHMARK DECISION
                                                                                                                                                                                            _
                                                                                                                                                  Federal Employee
                                                                               Medicaid                          HMO      State Employee Plans                             State Mandates
                                                                                                                                                  Health Benefit Plan
                                                                                                                                                 Blue Cross Blue Shield
Benefits
                                                                                                                                                    Standard Option
1. Ambulatory Patient Services
6. Prescription Drugs
Prescription Drugs                                                                                                                                        Yes
Preferred Tobacco Cessation                                                                                                                               Yes
(products must be prescribed by a physician and obtained from a
network retail pharmacy)
7. Rehabilitative and Habilitative Services and Devices
Physical, Speech, and Occupational Therapy (PT/ST/OT)                                                                                                       Yes
                                                                                                                                                  (combined maximum
                                                                                                                                                    75 visits per year)
Hearing Aids                                                                                                                                                Yes
                                                                                                                                                 (up to $1,250 per year)
Eyeglasses                                                                                                                                                  Yes
                                                                                                                                                   (once per incident)
Habilitation Services                                                                                                                                       NSP
Durable Medical Equipment                                                                                                                                   Yes
Medical Supplies                                                                                                                                            Yes
Breast Cancer Rehabilitation Services                                                                                                                       NSP
Prosthetics and Orthotics                                                                                                                                   Yes
Mastectomy Prosthetics                                                                                                                                      Yes
8. Laboratory Services
Diagnostic Test (X-Ray and Laboratory Tests)                                                                                                              Yes
Imaging (CT and PET Scans, MRIs)                                                                                                                          Yes
Breast Cancer Diagnostic Services                                                                                                                         NSP




Supported by a grant from the Robert Wood Johnson Foundation’s State Health Reform Assistance Network program.                                                                        Page 3_
                                                                                  ESSENTIAL HEALTH BENEFITS COMPARISON MATRIX
                                                                                       FOR MEDICAID BENCHMARK DECISION
                                                                                                                                                                                                   _
                                                                                                                                                    Federal Employee
                                                                               Medicaid                          HMO      State Employee Plans                                    State Mandates
                                                                                                                                                    Health Benefit Plan
                                                                                                                                                   Blue Cross Blue Shield
Benefits
                                                                                                                                                      Standard Option
1. Ambulatory Patient Services
9. Preventive and Wellness Services and Chronic Disease Management
Preventive Care/Screening/Immunization                                                                                                                      Yes
Vision                                                                                                                                           Expanded coverage available
                                                                                                                                                       under FEDVIP
Dental                                                                                                                                           Expanded coverage available
                                                                                                                                                       under FEDVIP
10. Pediatric Services (including oral and vision care)
Dental Check-Up for Children                                                                                                                     Expanded coverage available
                                                                                                                                                       under FEDVIP

Vision Screening for Children                                                                                                                                  Yes
                                                                                                                                                 (1 routine eye exam per year,
                                                                                                                                                           to age 19)
Eye Glasses for Children                                                                                                                         Expanded coverage available
                                                                                                                                                         under FEDVIP
General Pediatric Care                                                                                                                                         Yes
Miscellaneous
Chiropractic Office Visits                                                                                                                                 Yes
                                                                                                                                                 (maximum 12 visits per year)

Infertility Diagnosis and Treatment (i.e., endometriosis, blockage                                                                                            Yes
of fallopian tubes, varicocele)                                                                                                                        (with exceptions)
Weight Reduction Services                                                                                                                                     Yes
Acupuncture                                                                                                                                                   Yes
Wigs and Supplies (cancer or alopecia only)                                                                                                                   Yes
                                                                                                                                                 (limited to $350 per lifetime)

Genetic Testing                                                                                                                                              Yes
                                                                                                                                                 (women with family history
                                                                                                                                                 that shows increased risk of
                                                                                                                                                  certain genetic mutations)




Supported by a grant from the Robert Wood Johnson Foundation’s State Health Reform Assistance Network program.                                                                               Page 4_
                                                                                              ESSENTIAL HEALTH BENEFITS COMPARISON MATRIX
                                                                                                   FOR MEDICAID BENCHMARK DECISION
                                                                                                                                                                                                                                                               _
                                                                                                                                                                                                     Federal Employee
                                                                                          Medicaid                                 HMO                        State Employee Plans                                                       State Mandates
                                                                                                                                                                                                     Health Benefit Plan
                                                                                                                                                                                                   Blue Cross Blue Shield
Benefits
                                                                                                                                                                                                      Standard Option
1. Ambulatory Patient Services
Evaluation and Treatment of Chronic Pain                                                                                                                                                                       NSP
Reconstructive Procedures - covers medically necessary services                                                                                                                                                 Yes
for reconstructive procedures when a physical impairment exists
and the primary purpose of the procedure is to improve or
restore physiologic function
Temporomandibular Joint (TMJ) Syndrome or Dysfunction                                                                                                                                                  Surgery benefit
services                                                                                                                                                                                             when criteria are met

Abbreviations: CT = computed tomography; GEHA = Government Employees Health Association; MRI = magnetic resonance imaging; PET = positron emission tomography; PT = physical therapy; OT = occupational therapy; ST = speech therapy; NSP = Not Specified in
Available Documents; NA = Not Applicable




Footnotes
1
 The FEHBP BCBS Standard and Basic options cover skilled nursing facilities only when approved by a case manager.




Supported by a grant from the Robert Wood Johnson Foundation’s State Health Reform Assistance Network program.                                                                                                                                           Page 5_

								
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